Instructions
Before starting the SALLCo, the child should be placed in supine lying to determine if all
joints can be brought passively to a neutral position. The basic format of the SALLCo
assumes that this free range is available. If this is not possible, the test should be recognized
and noted as an adapted version of the SALLCo.
If testing full trunk control in standing reveals loss of static, active or reactive control, tester
should use Segmental assessment of trunk control (SATCo test) to determine or verify trunk
control before continuing with the SALLCo.
If limitation is present, a clinical judgment is made whether to focus on reducing the tightness
(if possible) or to ignore the joint limitation and assess and treat any control issues that are
below this level. For example, hip flexor tightness may be present and control cannot thus be
demonstrated through full hip range. However, an Adapted SALLCo can still proceed to
determine hip / knee control and full postural control.
Subject:
The subject is standing, with feet hip width apart on a flat and stable surface. The pelvic, hips,
knees, ankles and feet are orientated in a neutral position, and the subject is standing in an
upright posture. Leg length discrepancy should be compensated if needed, including during
testing barefoot. This is achieved by placing a flat board of appropriate thickness under the
relevant foot. AFO´s and shoes may be worn for the first three levels tested to assist stability.
The subject´s hands and arms should be free of all external contact including with own trunk,
thighs, or the tester´s arms and hands throughout the test. The subject´s hands should not be
joined together. Clothing should not obscure the trunk or the lower limbs, the subject should
be wearing shorts, with a close-fitting crop top, or preferably not wearing a top/t-shirt. While
being tested standing on one leg, subject will be given an instruction to lift the leg off the
ground.
Tester:
The tester applies firm manual support horizontally at each of the designated levels in turn as
indicated on the score sheet. The support given at each designated level should include
support to stabilize all distal joints to ensure that the body is in a neutral vertical posture and
that any collapse of the body is eliminated. This is likely to require an additional assistant.
Toys can be used to motivate a child, ensuring that the child turns towards the toy, but does
not grasp it, and the neutral vertical posture or the adapted position if necessary is maintained.
At each support level the tester encourages the subject to stand in a neutral vertical position,
with arms and hands free from the body, during testing of:
a) Static control: the subject is standing in an upright position, looking straight forward
for a minimum of 5 seconds.
b) Active control: the subject turns the head slowly to the right and to the left (>45o or to
limitation of range)
c) Reactive control: the subject remains stable during nudges. This requires an assistant
to apply a single brisk nudge from front to the sternum, to the C7 vertebrae from
behind, and from each side to the acromion, using the fingertips, sufficient to briefly
disturb balance. If a subject has minimal balance impairments they sway excessively,
but can return to vertical. If, however, they have moderate to severe balance
impairments they will lose balance and reach the limit of their range of motion with no
return to vertical position.
The test continues with lowering of the support level until the subject clearly cannot maintain
or quickly return to the starting posture. The tester should be positioned behind the subject,
usually in kneeling, depending on the size of the subject. The assistant should ideally be
positioned out of the subject’s vision, and a third person may be required to support more
distal joints.
Optional Video Instructions
If videorecording is possible, it is recommended to record the assessment. This secures a
visual documentation for future reference and also allows review of the test in case of
ambiguity in scoring. If video tape is used, a camera set up at a 45 degree angle to the subject
will usually allow movement to be judged from the front and side views sufficient to detect
movement strategies.
Scoring Guidelines
Definition of Control:
Stable neutral vertical standing position (brief deviation of no more than 20o) in both frontal
and sagittal planes. The normal cervical, thoracic and lumbar curves should be present with
hips and knees in neutral.
Scoring
At each level of support the presence (!) or absence (-) of control is recorded. (NT) indicates
not tested. Presence of control is shown by:
a) Static: the subject can maintain a neutral vertical standing position in the sagittal and
frontal planes for a minimum of five seconds. If the subject’s attention is briefly lost,
accompanied by a head turn, but a neutral vertical standing posture is maintained, this
is still scored as presence of control.
b) Active: the subject can maintain a neutral vertical standing position, while turning the
head to the left and to the right, without trunk movement. A slight displacement from
the neutral position may occur, e.g. hip and/or knee flexion, hyperextension in knees
or trunk flexion (<20°). For active control to be scored as present, the subject needs to
realign immediately by most direct route, e.g. trunk flexion should be corrected by
extending to a neutral trunk posture, rather than by circling through trunk side flexion.
c) Reactive: Subject will move away from neutral vertical standing position but quickly
return to neutral vertical by most direct route.
You score only what you see:
If control is not demonstrated, score as absence of control (-) or not tested (NT). If you
believe that the child is able to maintain control, but when tested is not able to demonstrate
this, then it must be scored NT. Likewise if the tester made an error of alignment that prevents
assessment of true neutral vertical control it must be scored NT. NT should always contain a
comment regarding the nature of the error for future reference.
Be aware of compensatory strategies that may indicate a lack of normal control
Hand support
•
In mouth
•
On body (own, tester’s or assistant’s)
•
Together (on toy/object or clasped)
•
On toy/object held by the tester
Trunk alignment
•
Leaning forward in trunk flexion
•
Arching backward over manual support
•
Collapse beyond normal curves
Lower limb alignment
•
Increased anterior or posterior pelvic tilt
•
Lateral plane (abduction/adduction) or rotation at the hips resulting in a standing
position that is not neutral vertical or is not quickly restored to neutral vertical
position
•
Increased internal or external rotation at the hips
•
Increased flexion or hyperextension of knees
•
Increased supination, pronation or dorsiflexion/plantarflexion in ankles
Movement strategies
•
Stiffening in form of rigidity with lack of movement of the body above the level of
support
•
Rapid movement rather than a slower controlled movement, e.g. of the head
Critical tester errors:
Hand support
•
Not horizontal
•
Not sufficiently firm and stable
Trunk and lower limb alignment
•
Body below support level not held in a neutral vertical position
•
Collapse of trunk
•
Movement of lower limbs not eliminated
Movement
•
Poor placement and/or magnitude of nudge
•
Nudge during non-vertical alignment
Critical scorer errors leading to incorrect determination of control level:
•
Obscuration by adipose tissue
•
Discriminating loss of control from habitual posture
Level of Control Specification:
•
The focus is to determine the highest level at which subject demonstrates loss of
control and this is scored as absent control (-)
•
Not Tested (NT) at a level above a check mark (!control present) is counted as
having control at that level
•
Not Tested (NT) at a level below check mark is counted as loss of control at that level
If static balance is NT but subject held the alignment during reactive or active then static is
given credit as having control (!)